the use of hypnosis in the care of the cancer...

T H E USE OF HYPNOSIS IN T H E CARE OF THE CANCER PATIENT

BYRON BUTLER, M.D., MED.SC.D.

T IS ONLY THE MIND that is important in can- I cer, for it alone carries the burden of the disease.37 Hans Zinsser expressed this thought when he said: “As it is, my mind and my spirit, my thoughts and my love, all that I really am, is inseparably tied up with the failing capacities of these outworn organs.” Philosophically, only mind is important.

We need not stress the treatment of cancer, for that is the main intent today. The attack on cancer has been so consistently emphasized that the emotional aspect of this disease is entirely in the background. At this time when radical surgery, high-voltage radiotherapy, glandular extirpation, hormone administration, and radioactive drugs are used freely, it may be timely to appraise that cancer patient who is an individual with a death sentence. Most of us with our occidental philosopsy of life, believe that death is the end of conscious- ness, and few approach it without the feeling of Hamleto? when he said that death is a land Erom which no traveler returns. Certainly, this threat of extinction is the most difficult problem the conscious mind has to reconcile.

This psychological approach may be traced to Freud’s4 revolt against the cellular philos- ophy of Virchow, and, as a result, our knowledge of functional disease has been greatly enriched.3. % 16, 22* Mental factors in what were previously considered to be purely organic disease, such as hypertension,2, 48 diabetes29 tuberculosis,6 ulcerative colitis,17 and peptic ulcer, Cave been demonstrated. Finally Virchow’s own citadel has been invaded, and the cancer patient has been found to exhibit defenses iden- tical with those observed in psychoneurotics.e*

As the microscope, Virchow, and Pathology led to the great advances in exact laboratory investigation and physical medicine, so did mesmerism, Freud, and Psychiatry lead to an

From the Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia Univer- sity, Sloan Hospital for Women [Columbia-Presbyterian Medical Center] and the Francis Delafield Hospital, New York, New York.

Partially supported by a grant from the American Cancer Society, Lnc.

Received for publication. April 24. 1953.

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understanding of the mind. Since i t has been clearly indicated that there are important emotional disturbances in patients with cancer,68 it is to be expected that these reactions will vary from patient to patient. If the emotional ten- sion present in these patients can be channeled away from a neurotic exaggeration of fear and self-pity to a more constructive and realistic point of view, then this energy could be available to support the patient during therapy and, when that is finished, to give him a more serene and confident attitude until the end. With such an approach there will be less pain, less disturbance in bodily function, and a reduc- tion in the degree of dread that surrounds the subject of cancer.

Hypnosis has many attributes that lend themselves to this problem. Indeed, it can be used to suppress symptoms or through application of analytical principles to express emotionally charged ideas. It allows, at least in some patients, a control over the subconscious mind in spite of resistance by and without the knowledge of the conscious mind. Thus, the mind can be maneuvered to aid the cancer patient in his struggle for survival. The therapist is like the master of a marionette, who can manipulate his charge as required by the occa- sion. The act can run smoothly if the master is capable of his task, but it may be disastrous if he does not know each phase of the plot.

HISTORY

Arnold J. Toynbee has made history a useful study, for from it one learns not only what has happened in the past, but also what may occur at the present, and what is likely to develop in the future. I t is in this vein that a brief sketch of the history of hypnosis is presented.

Hypnosis is older than medicine. It was used by the adepts before the medicine men had separated from the priests. More than 3000 years ago it was used in India2’ and in the British Museum there is a bas-relief taken from a tomb in Thebes that shows an Egyptian hyp- notist and his ~atient.~T Aesculapiusl5. 72 was able to relieve pain by stroking with his hands

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to induce long and refreshing sleep in his patients, while, according to Tacitus,lb Hippoc- rates spoke of impressing health on the ill by “passes.”

T h e pertinent history of hypnosis can be divided into four periods. Each period has been characterized by a crescendo, a fortissimo, and finally a pianissimo.

I. Period of Magnetism (1587-1789). The first period began with Cardan’s Works on Precious Stones, 1584,s in which he reported an experiment whereby anesthesia was produced by a magnet. P a r a c e l ~ u s ~ ~ believed that the human body exhibited magnetic properties, and in forbidden writings Maxwel1,s van Hel- mont,72 and others propounded the theory that in the magnet one could find the universal principle that could explain all natural phenomena. Influenced by these writings and his own doctorate thesis, De Planetorunz Influxir, 1766,53 Franz Anton Mesmer formulated his brilliant theory on animal magnetism, which he published in Paris in 1779.30 This theory was summarized in twenty-seven propositions or axioms, which postulate that there is a “magnetic fluid” that permeates the whole universe. It is because of this that “impressions” from one part may be transmitted to and may influence another; for to this incomparably rarified sub- stance there is no vacuum. This material may be communicated, propagated, and concen- trated by sound, mirrors, and light. He believed that his “fluid” was important in medicine and that, when the physician understood it, he could diagnose, cure, and prevent disease. This theory is today still thought-provoking, for fundamentally the first part differs little from a theory of the universe presented recently by Herbert L. Samuel. Mesmer became fascinated with the “crises” he produced and thought the proof of his theory required curing of illness by this means. The Commission appointed by Louis XVI denied him this evidence, and from their experimental studies they concluded that these “crises” were due to the imagination of the patient. The investigators coidd neither feel, hear, nor see “animal magnetism,” therefore how could it exist? Also they showed great concern about the possible moral abuses of it,a* 52 for was not the subject the pawn of the magnetizer’s will? With this crushing defeat Mesmer left Paris, but before this great first chapter closed Count Maxime de Puys6gur,lg a pupil of Mesmer, demonstrated the phenomenon of “somnambulism” and described how, on awakening, the subject had complete amne-

sia for the trance period. He also called attention to the ability of the somnambulist to feel and describe accurately conditions in other bodies and to prescribe cures for them. Edgar Cayce’s work utilizing this phenomenon ten to fifteen years ago has been reported in Theye Is a River.71 PuysCgur’s work, however, could not reverse the charges already made, and animal magnetism slipped from prominence with the upheaval of the French Revolution in 1789.

II. Mesmerism (1823-1860). When the French Academy appointed a second Commis- sion of nine men to restudy magnetism in 1823, a revival of interest occurred. After a five and a half year period this Commission reversed the opinion of the first. They concluded that “research on magnetism should be encouraged as constituting a most curious branch of psy- chology.”B

T h e Commission undoubtedly realized that there was something to mesmerism when they observed the following case, which was referred to by Pyne, Elliotson, Hollander, and Didier.

Briefly, M. le Docteur Chapelain had used mesmerism over a period of several months to relieve the suffering of Madame Plantin, who had an ulcerated cancer of the right breast with massive enlargement of the right axillary lymph nodes. He was able to induce “a profound sleep in which sensation appeared sus- pended, but intellect remained perfect.” On April 1, 1829, in Paris, Chapelain “threw her into a mesmeric sleep” and Jules Cloquet removed the breast and dissected out the axillary nodes. The operation lasted ten to twelve minutes and during this time the patient conversed calmly with the operator and gave not the slightest indication of pain. The wound was closed with sticking plaster. The patient was pvt to bed and left in a mesmeric state for ten hours.

An important figure at this time was John ElliotsonzE of London, who introduced Laen- nec’s stethoscope into England. He was also the first Professor of the Practice of Medicine at the University Hospital, 1831. Elliotson believed in Mesmer’s theory and staked his rep- utation upon the belief that a coin of nickel would mesmerize, while a coin of lead would not. When, in a crucial experiment, Thomas Wakely, the editor of the powerful Lancet, switched the coins by subterfuge, of course, Elliotson was defeated. He was forced to give up his academic position but continued to have a large practice, published a new journal, T h e Zoist, and had such eminent admirers as

No. 1 USE OF HYPNOSIS IN CARE OF CANCER PATIENT - Butler 3

Charles Dickens and William Thackeray. El- liotson described:

The case of a man whose right knee was like “a bag of bones.” The patient was in such agony that he had not slept for three weeks, could not eat, and had excruciating pain if anyone walked heavily across the room. He was mesmerized on three successive days. His pain was relieved and he ate and slept. On the third day his leg was amputated above the knee without evidence of pain. When he was awakened, he did not know the operation had occurred.

James Esdaile, inspired by Elliotson, used mesmerism to perform painless operations upon the natives of Bengal. In 1846, he performed seventy-three major operations and relieved pain in eighteen medical conditions. He used trained natives to perform the mesmeriza- tion, while he performed the operations. Most of his cases were witnessed by reliable observers, who traveled great distances to his little coun- try hospital in Hooghly, India. He was later to learn upon his return to England that the philosophical, oriental mind of the Bengalese lends itself to a greater depth and a greater ease of induction than the mind of the average Englishman. The native magnetizers used passes mainly, and certainly, in this accurate record of profound mesmerism, there was little use made of suggestion, which is thought to be all-important today. In every case reported by Esdaile there was irrefutable evidence of control of pain, and at least twelve of his cases could have been cancerous tumors. Typical of his cases is the following report:

“Oct. 25, 1845. G. S., a shop-keeper, aged 40. He has a ‘monster tumour,’ which prevents him from moving because of its great weight. He has used it for a writing desk for years. He became insensible on the fourth day of mesmerism, and I removed it with a circular incision. The rush of blood was great, but was soon arrested. The tumour weighed eighty pounds. On recovery, he said that nothing had disturbed him.”

Didier reports in detail:

A case of cancer of the breast which was removed by Mr. Tubbs in 1854. The patient was mesmerized, the breast and axillary nodes removed, and the wound edges sutured. The patient was awakened and stated without res- ervation that she felt no pain during or after the procedure. Doctor Elliotson, Col. Baynold, Dr. Symes, Mr. Goff, and Mr. Amon were witnesses.

With the discovery of chloroform62 and ether13 this period of attempted useful application of mesmerism came to an end.

ZZZ. Braidism-Hypnotism (18434900). With James Braid, a Manchester surgeon and oculist, we enter the scientific phase of hypnosis.9 Braid recognized that with the induction of the mesmeric state, the eyes exhibited a peculiar type of movement that he thought was of a reflex n a t ~ r e . 7 ~ He broke away from Mesmer’s theory and believed that the “state” resulted from some physiological change in the individual induced by tiring the eyes, and this resulted in a peculiar physiological condition of the brain and the spinal cord. It was Braid who recognized the importance of suggestion and devised the name “hypnosis.” Volgyesi considers that he was not only the founder of scientific hypnotism but also the father of psychosomatic medicine.

The Nancy School, largely represented by LiCbeault56 and Bernheim, believed that hypnotism was closely allied to natural sleep and was largely a product of suggestion, while the Paris School, headed by the noted neurologist, Charcot, thought that it was a pathological state, a neurosis, and that it was due to a somatic change. There was great rivalry between these two groups, but the Nancy School won out and received official recognition from the Academy of Medicine in Paris.7. 86 The use of hypnotic and suggestive therapy became comonplace throughout the world, but there was little attempt to select suitable cases, nor could it live up to the exaggerated claims made by its proponents. By 1900, it fell into disuse again.

During this period, however, it was directly applied to the control of pain in a few cancer patients. Tuckey referred to reports by Arthur of the East-End Wesleyan Hospital:

Arthur used hypnotism to relieve pain in cases of cancer of the uterus and breast and, by this means, he achieved excellent palliative results. The pains, however, returned from time to time, and it was impossible for the patients always to go to him for relief. He, therefore, hypnotized them and told them that, whenever their symptoms recurred, they had only to take a dose of the medicine he would give them, and they would experience immediate relief. This procedure was successful and he termed this method “treatment by indirect suggestion.”

I V . Hypnology, Narcoanalysis, Hypnoanaly- sis (2900-1953). During the past fifty years through the application of laboratory experi-

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mental techniques, hypnotism has become es- tablished as a science.36 “hypnology.”12. 75

Those who use this science constructively may be called “hypnologists.” This science has a secure basis with its tenets anchored on experimental measurements. Thus, muscular strength,57. 81 cerebral function,28* 46* 69 gastric secretion,45 and respirat0ry3~ and cardiovascu- lar actions39.449 76 have been studied as they are influenced by the hypnotic state. Also pertinent to this report are experimental investigations of hypnotic anesthesiaz3- 59v upon which is based the rationality for the use of hypnosis to relieve pain in cancer. Its effect upon recall of past memories,38 the duration of posthypnotic amnesia,TO and even its possible antisocial useslo. 259 64, 77, 79, 80 have been scrutinized. Be- cause of this, there has gradually been a dimi- nution in both professional and popular resistance to hypnosis.

Another impetus to social acceptance was the development of narcohypnosis and narcoanaly- s i ~ . ~ ~ ~ 34 The use of drugs made these pro- cedures more acceptable.

It has been said that if psychotherapy is ever to reach the masses, it will be through a method more rapid than psychoanalysis, such as hypnosis. This challenge has been acted upon by Brenman and Gill11 and Wolberg, who have combined hypnosis and psychoanalytical principles into an integrated form of mental therapy, “hypnoanalysis.”

During this fourth period there were also a few isolated reports on the use of hypnotism to relieve the pain of cancer. Miller refers to a case treated by Betts Taplin:

His patient was a 66-year-old man who had a carcinoma of the cardiac end of the stomach diagnosed by a laparotomy. Taplin describes his results in the relief of suffering in this patient who was getting morphine frequently and was losing ground rapidly one month postoperatively. “I resolved to try what hypnotic suggestion would do toward smoothing the way to the inevitable end. The result exceeded my expectations. After the first sitting he was much easier, and slept fairly without his mor- phia; after the second, the pain disappeared for three days, and returned (not severely) just before the third sitting; after that it passed away altogether, leaving slight discomfort after food only. As the sittings continued, even this disappeared; he was able to take solid food with comfort, his out-standing trouble, consti- pation, passed away, he slept well nightly, and began to gain strength and to put on flesh, and is now, three months after I began treatment,

eating and digesting ordinary food with ease, to all appearance in good health and weighing two stones heavier; nothing but a little weakness in the back after his long suffering and illness remaining. In any case, hypnotic suggestion has done more for him than I believe any other treatment could have done.”

In 1932, Hollander reported a personal experience on relieving the pain of a cancer patient with hypnosis:

“Once I was asked by a surgeon to go to a nursing home in Hampstead, where a young woman, dying from cancer of the uterus, suf- fered great pain which caused her to be sleep- less. Within a few minutes the patient was asleep, and, in a few minutes more, wide awake with spasmodic pain. I persevered for an hour, at the end of which she seemed more peaceful. I heard no more for a week, when I received a letter thanking me for what I had done, stating that the patient had slept free from pain every night since my visit.”

Rosen reported the use of hypnosis to control pain in seven patients with various conditions. He was able to obtain hypnotic anesthesia in 25 per cent of his cases.

His only cancer patient was a 39-year-old woman with bone metastases from a carcinoma of the breast. Because of severe hip pain, un- controlled by morphine, she was hypnotized twenty-four times during the last six weeks of life. She was undisturbed by pain during the hypnotic period, but the pain was not controlled posthypnotically. Rosen thought that a prefrontal lobotomy would have been pre- ferred to hypnotherapy, since the patient had derived only partial relief from the latter.

THE HYPOTHESIS

The hypothesis that the mental and physical disturbances of the cancer patient may be fa- vorably influenced by hypnotic suggestions evolved during thirteen years of critical investigation of hypnotic phenomena by the author. At first, over a period of six years, hypnosis was used as a tool to study psychological functions of the mind. Experience was gained in selec- tion of suitable patients, means for allaying unfounded fears and misapprehensions, methods for inducing the hypnotic state, and pro- cedures of elicitation of various hypnotic phenomena. Approached critically and skeptically, it was only after repeatedly reproducing the various phenomena of hypnosis that the con- clusion that hypnotism is a “real” phenomenon became inescapable.


Defined broadly, mind and body are insep- arable, and, as a corollary, since hypnotism is a means of control of the mind, i t can also regulate the body and its functions. With this hypothesis one can extend the use of hypnosis beyond psychological processes and apply it to the vast field of psychosomatic medicine. Exem- plary of this field, seven cases of severe primary dysmenorrhea were treated. The hypnotic states were induced, painful periods were “abreacted,” and positive posthypnotic suggestions were given for the patient to be free of menstru- al cramps, headaches, nausea, and vomiting. From two to twelve treatments were given at monthly intervals. Superficial psychotherapy was also utilized. Six of these cases, which were completely unamenable to all other medical therapy, were symptomatically cured to a follow-up of two to five years. Others have also found hypnotherapy effective in otherwise re- fractory cases.20~ 41 42

When this hypothesis is carried a step further, control of painful organic conditions should be possible. In this respect during the past six years, the author used hypnosis to facilitate the care of twenty selected obstetrical patients. Hypnosis was used successfully in relieving severe nausea and vomiting during the early months of pregnancy, in the elimination of heartburn, in alleviating back and muscular pains, and in allaying fear and anxiety. Also, at the time of labor and delivery, it was successful in partially or completely relieving the pain of the entire labor. Through the use of hypnosis, infants were delivered spontaneously, and by breech, without anesthesia. In two cases, episiotomies were made and repaired with the patient experiencing or remembering little or no pain. Postpartum, lactation could be influenced. In two cases, postpartum depression responded to positive supportive suggestions. Similar results have been obtained by others.’,

The application of this same successful technique to gynecological cancer patients being cared for concurrently by the author was an unavoidable progression; for, more than any other group of patients, the cancer patients need mental-physical therapy.

40. 41. 43, 64

METHODS AND PROCEDURE

Cases for this study were gradually accumu- lated from referrals by various physicians who thought their patients were particularly in need of and suited for this form of therapy.

These were patients with pain and widespread cancer. Frequently, they were emotionally disturbed and had been difficult nursing problems. In these cases the usual form of medical care, including sympathetic and understanding attention and the administration of various pain-killing drugs, had not been entirely satisfactory. Also, hypnosis was suggested as a last resort before considering a prefrontal lobotomy.

The patient referred for treatment was interviewed, and a detailed history was obtained with special attention to psychosomatic factors, previous impressions of hypnosis, and the present social mesh in which the patient was caught.

The subject of hypnosis was forthrightly dis- cussed, and, if the patient was co-operative, the hypnotic procedure was started. Attempts were made to have the patient in a relaxed position, either sitting or prone, in a darkened, quiet room. There was always a “disinterested” third person present. The techniques used to induce hypnosis were eye-fixation with attention fo- cussed on a small bright light, coin, or crystal,9 hand levitation,gO* 82 or lid closure with eyeball pressure by the fingertips.s

Appropriate verbal suggestions were given depending on the style of induction and the personality of the patient. Soft, soothing, classi- cal music was played on a phonograph, not only to help the patient relax but also to eliminate extraneous noise. When the operator suspected a light stage of hypnosis had been obtained, he commanded that the patient could not open his eyes. If this order was effective, progressively more complicated and more elab- orate mental pictures were constructed. A float- ing or light feeling was usually easily obtain- able, as well as epigastric warmth. Then, in sequence, extremity rigidity, “automatic” movements, visual and auditory hallucinations, and anesthesia were elicited. Posthypnotic phenomena were produced when the depth of hypnosis obtained would permit it. After the greatest depth possible was reached, pertinent suggestions were made to remove disabilities and pains, and positive commands given as demanded by the situation. When abreaction of some relevant event in the patient’s memory was indicated, this was elicited. The patient was then awakened. His experience was dis- cussed with the hypnologist and superficial psychosomatic guidance was given.

Narcohypnosis was used in some patients who had a superficial resistance to the usual

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technique of hypnotic induction. While either sodium pentothal or sodium amytal was given slowly intravenously in a very low concentra- tion, the hypnotic techniques were followed as used in the regular patients. A state of con- scibusness was maintained as much of the time as:‘possible. Some patients, following this procedure, became excellent hypnotic subjects and no longer required the drug. I n strongly re- sistant cases, the drug did not influence the patient, and resistance was evident even when the maximum drug was given. It appears that nar- cosis and hypnosis are dissimilar states, although one may aid the other when used con- jointly. Narcohypnosis was not used to any great extent because of the ever-present risk of sudden respiratory or cardiac failure.

The frequency of the treatments varied greatly. Out-patients were seen daily or weekly; hospitalized patients were seen at least daily and sometimes two to four times a day. Because of the amount of time required, phonograph recordings were made for specific patients on twelve-inch records at 33% r.p.m. in a recording studio. Agairi, the technique and suggestions previously found effective for that patient were specifically recorded, and effective, selected music was recorded simultaneously as a background. An automatic phonograph was placed at the patient’s bedside, and, when the patient was in a ward, the phonograph was sup- plied with headphones, so that adjacent patients were not disturbed. Either the patient, doctor, or nurse could start the recording; it would stop automatically.

The effect of the phonograph records was usually good, but they were not so effective as personal contact with the hypnologist. Also, the patient soon memorized the record and tired of it. New records were made to combat this, and new suggestions included when indicated. Personal hypnosis was continued at intervals while the records were being used to give the patient further support.

When hypnotherapy was stopped for the purpose of determining the effect of its with- drawal, i f done suddenly, there was a dramatic and severe change for the worse. It was as if a prop had been knocked away. Pain became more intense, disabilities increased, and the patient was now more difficult to care for than before. If the hypnotherapy was gradually withdrawn, the patient could be maintained greatly improved without the actual use of hypnosis until that time when pain suddenly recurred or some other event demonstrated to

the patient that his course had again turned downward. Then hypnosis was used again to recover lost ground, but, each time this happened, i t was more and more difficult to return the patient to the same emotional level of confidence and cheerfulness; for, each time, the “truth” became more firmly imprinted and harder to erase.

I n all of this, the depth of hypnosis is the deciding factor. For practical purposes there are three stages: light, medium, and deep trance. In a light trance, the patient recognizes some “influence” but doubts that he was hypnotized. In a medium trance, the patient is sure he was hypnotized, but he can recall freely all the events that occurred. In a deep trance, the subject realizes that he was hypnotized, but his recall of the trance period is under the control, to some extent, of the hypnologist’s suggestions. After three one-hour periods of intensive work, cancer patients who reach only the light trance cannot be helped. Those who go into a medium trance can be helped but, the more severe and “organic” the pain, the more ephemeral the hypnotic control. Those who reach the deep or somnambulistic trance can be helped. Unfortunately these people are rare and constitute only 10 to 20 per cent of the population. Extensive disease, a distraught mind, pain, and the fear of death make induction of hypnosis more difficult than in normal people, because it seems that the most difficult thing to control under hypnosis is the function you want most to affect.

The hypnologist is an important factor in this problem, for hypnosis is a transference and countertransference relationship just as is psychoanalysis. In hypnosis this interplay is not well understood by either party and is not well handled. Here, the differences in sex, age, race, and social station of the patient and the hypnologist become acutely important and may, if these factors are adverse, militate against success.

Since Braid limited the role of the hypnologist and expanded the importance of the subject, there has been practically no study of the effect of hypnosis upon the hypnologist. The hypnologist is, however, affected by the treatments. He gives of himself to the patients, and he receives the discards from them. If he is in good health, comes in contact with the patient only at intervals, and takes his work lightly, he will be unaware of this, and there will be little affect. If the reverse is true, however, he will gradually feel his vitality become reduced and


will become more susceptible to illness himself. Even an hour’s treatment with a very sick patient can produce an appreciable tiring of the hypnologist, and, as the sympathetic bond between the two grows stronger, the hypnologist may even “feel” the symptoms he is trying to eradicate from the patient.

W. L. Howard also found that the effect upon the operator may be “very severe,” and that, when the hypnotic treatments are “con- tinually kept up on several cases without mental rest, i t may produce some very injurious conditions” in the operator. William Davey advised, “If the operator labours under any deficiency of healthful vigour, the frequent contact with diseased individuals will be sure, by the law of mesmeric sympathy, to affect him with pains and disquietudes, i f not perfectly analogous to those of his patients, yet bearing such relationship to them, as will suffice to make him painfully conscious of the source whence they are derived.”

However, with an expenditure of considerable time, energy, and ingenuity, a very sick suffering patient may live his last months of life with a minimum of drugs, a sense of hope- fulness and cheerfulness, and relative freedom from pain. His mind becomes more acute rather than dulled, as with drugs. The rest of his body functions as well as it can without being further inhibited by drug side-action. He is a rational thinking human until death, rather than a “vegetating” invalid as may hap- pen after a prefrontal lobotomy. He has been supported in the last days of his life by the compassion of his physician rather than let down with drug addiction and destructive surgery.

In summary we have the mind of the patient struggling for survival, aided by the mental support of the hypnologist; both are fighting a losing battle, for, in the end, cancer and death will win.

CASE HISTORIES

Case 1. Mrs. M. B., age 55, received morphine, 15 mg., every four hours for relief of lower abdominal pain. The tentative diagnosis on admission was carcinoma of the ovary with metastasis. A hypnotic state was induced easily during which suggestions were made for the patient to be free of pain and to become calm and relaxed. After the second treatment her pain was improved, and she required one half of her usual amount of morphine to keep her free of pain. She was so deeply entranced on

the second attempt that there was complete loss of the corneal reflex, loss of sensation to painful stimuli, and complete amnesia to the entire trance period. She was a somnambulist.

On the third day, it was decided that the diagnosis must be confirmed, and then an ex. ploratory operation was indicated. Since the patient was in a poor physical condition, hyp nosis was suggested as the form of anesthesia. Again the patient was placed in a deep trance. After two hours, when she had lost the corneal reflex but still carried out suggestions, she was taken to the operating room. The abdomen was prepared and draped, and, with no other form of analgesia or anesthesia except hypnosis, an incision 10 in. long was made from the umbilicus to the symphysis pubis. Skin towels were applied, and the incision was carried down to the fascia through 3 to 4 ,in. of subcu- taneous fat. As the fascia was being incised, the patient moved but did not complain of pain. With this, however, cyclopropane anesthesia was started, and without waiting the exploration was continued. Carcinomatosis was found; the ovarian tumor was biopsied, and the incision closed.

Postoperatively, the patient stated that she had felt no pain at any time; however, she also had no memory concerning the period of time during which she was hypnotized.

Her physical condition then deteriorated rapidly, and she died three days later. Since she had no further severe pain, hypnosis was not used after the operation.

Case 2. Mrs. M. R., age 48, was admitted to the hospital because of a tumor the size of a six-month pregnancy that filled the pelvis and lower abdomen. It was a rapidly growing sar- coma of the uterus. The patient was in severe pain. It required the assistance of three people to move her in bed, for movement made the pain more acutely excruciating. She had been bedridden for six weeks and was anorexic and constipated. Consequently, she was depressed, frightened, and morbid. She suspected that she was dying of cancer.

With the first attempt at induction she entered a deep somnambulistic trance. It was suggested that she was free of pain, fear, and anxiety. She was told to get out of bed and walk. This she did with but little support. When she was awakened and told of her prog- ress, it seemed incredible to her. Actually she was free of pain and could move in bed easily. She ate better than she had in weeks and slept without medication.

During the next three weeks, the patient was kept in a hypnotic state 30 to 40 per cent of the time, and she found that she could take food and control her bowel elimination by giv- ing herself suggestions. She was able to get out

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of bed alone and to walk unaided; also, sht was eating well. She required no analgesic agent.

She had a particular dread of her daily trip to the radiotherapy department. Since she would stay in a trance two to three hours without waking, she was hypnotized in her room and told not to awaken until after she had returned from her treatment. Thereby, she had no memory of this experience and, hence, no dread. It is pertinent to state that the tumor grew rapidly in spite of radiotherapy.

When hypnosis was discontinued, but the same amount of personal attention to the patient was maintained, the patient did well for thirty-six to forty-eight hours; then she would gradually slip back into her previous condition. She would con,,Aain of severe abdominal pain and weakness, be unable to get out of bed, and have again a strong fear of dying. Then, with as little as five minutes of hypnosis with appropriate suggestions, she would awaken free of pain, strong, and liberated from anguish.

By the end of the second month, a phonograph record was made from a tape-recording of a hypnotic treatment at the patient’s bedside. The record was then available for the patient to play on a portable phonograph in her room. This record, at first, induced a deep state of hypnosis, but later, as the patient memorized the words, she became annoyed with it, and it became less effective. Then other records were made for specific uses: to induce sleep, to relieve pain, to restore calmness and confidence. By using a variety of records, the patient was maintained and required personal hypnosis only once a day.

By the end of the third month of hypnotic treatment, the tumor had grown to the size of a term pregnancy. T h e bowel was partially obstructed and vomiting became difficult to control. The records were not effective, and the patient was kept in a trance most of the time by personal hypnosis. Even when the tumor ruptured and drained a copious foul necrotic material out of the vagina, the excruciating pain was quickly relieved by inducing a deep trance. Soon after this the patient died.

Case 3. Mrs. I. M. was a 65-year-old actress and dramatic coach, who had had a radical mastectomy two years previously because of cancer of the breast. She complained of pain in the occipital portion of her head that radi- ated down both arms. Her right arm was weak, so that she could no longer lift a glass or cup. She could not write, and she was incapacitated by the pain so that she could not teach. Roent- gen-ray examination disclosed that she had metastatic lesions in the cervical vertebrae, ribs, ischiurn, and right femur. Radiotherapy had

been given to the cervical region without relief of pain.

Over a period of two weeks the patient was hypnotized ten times. She entered the somnambulistic stage and could be made anesthetic to painful stimuli. During this period she was able to get out of bed and walk unassisted. Her pain became less and she regained the use of her right arm so that she could lift a pitcher filled with water and could write. She regained her courage.

When she was in the hospital she used a record to help her at night. At the end of this time she returned to her studio and actively taught dramatics again. No further hypnotherapy was used.

One month later, however, the pain returned and the patient had to be readmitted to the hospital. Finally, a prefrontal lobotomy was performed on the right side of the brain, but, when the pain continued unabated, in fact was even more severe, hypnotherapy was tried again. Now, five months after the first successful use of hypnosis and one month after the lobotomy, the patient had a clear sensori- um and a good memory, but i t was difficult for her to concentrate. She complained of severe pain in her right thigh, where she had a pathological fracture of the femur, a severe pain over the left side of her head, and a heaviness of her face. Pain had become so severe that she required morphine every four hours.

Hypnotic techniques were used, but she was now very sick and debilitated. She said that she wanted to die and resisted my suggestions. Also, since she had had the lobotomy, con- centration was difficult. Only a medium trance could be induced and that required great effort and time. After five long sessions over a period of eight days, there was subjective improvement. T h e phonograph and recordings were used at night. Pain became less and appetite returned. There was some improvement because of the hypnotic treatments, but it was neither striking nor dramatic. Soon after this the right hip was nailed, her condition became rapidly worse, and she died.

It is worthy to note, first, that this woman who was very intelligent, independent, re- sourceful, and successful, found it difficult to adjust to a dependent role. Also, there was a certain sense of persecution about her pain, which came in “spasms” and which she associ- ated with “people coming after her.” She believed her present suffering was a punishment for her inconsideration of others during her life. Prefrontal lobotomy in this patient inter- fered with the hypnotic state because concen- tration was more difficult.


Case 4. G. P. was a 14-year-old boy who had acute myelogenous leukemia. He was referred for treatment because of severe pain in the coccyx, depression, apathy, and anorexia. He was anemic and had responded poorly to trans- fusions.

This boy was interviewed and hypnotized six times over a period of one week. On two occasions he was in a somnambulistic trance and on the other four reached only a medium trance. Nevertheless, his pain was entirely relieved while under hypnosis, although it would return three to six hours after the treatment. He became congenial, his appetite returned, and he felt a return of his normal vigor. Actually, his hemoglobin increased 1.0 gm. during this period, although he received no trans- fusions, and, by the end of the week, he required no medication for pain.

Six days after this a perirectal abscess was discovered as the cause of the coccygeal pain and, following incision and drainage, there was continued subjective improvement. The patient left the hospital and returned home. He did well on supportive therapy. Four months later, he inadvertently read a letter that disclosed to him the lethal nature of his disease. A relapse immediately followed this experience, and he was readmitted to the hospital. He died eight weeks later. Hypnotherapy was not used during this last admission.

Case 5. Mrs. I. R. was a 72-year-old colored woman, who had a carcinoma of the right parotid gland, which had been treated with radiotherapy during the past year. As a result her face was distorted by a seventh nerve paralysis, and, from the onset of the radiotherapy, she had a bad taste in her mouth. She was troubled mostly, however, by excessive salivation that had not responded to any type of treatment and by the anorexia related to these disturbing symptoms. She also had pain in the right side of her face and neck. In addi- tion she was confined to bed or a wheelchair for the past month owing to deformity of her legs by rheumatoid arthritis.

The patient would enter a medium trance and, during one week when she was seen six times, the bad taste, face pain, and excessive salivation were controlled during the hypnotic period and for as long as twenty-four hours posthypnotically. First, while in a trance, and then, when entirely awake, the patient was ambulated, and by the end of the week she was walking around the ward unassisted. Her appetite improved &d she ate well as long as her symptoms were under control.

Hypnotherapy was stopped and all her symptoms returned.

Three weeks later a prefrontal lobotomy was performed on the right side, but following this

there was no improvement. The patient was very weak and bedridden. Two weeks later hypnotherapy was tried again. Although difficult to evaluate because of a mental lethargy and dullness, it was possible to elicit a few hypnotic phenomena during two interviews. The depth of hypnosis, however, was definitely not so great as had been obtained before the lobotomy had been performed, and the efficacy of the treatment was doubtful. Because of the patient’s poor condition further attempts at hypnosis were not tried. She died ten days later.

Case 6. E. B. was a 49-year-old man with secondary carcinoma of the liver. The primary site was unknown. He was jaundiced, the liver reached the iliac crests, and he was unable to eat. Hypnotherapy was utilized in an attempt to combat the anorexia.

After five interviews during one week only, a medium trance could be induced. However, a definite and prolonged improvement in his appetite occurred with a consumption of a greater amount of food than previously. Real hunger could also be suggested. After therapv was stopped, the anorexia returned, and threc weeks later the atient left the hospital. He died at the end o F ten weeks.

Case 7. Mr. M. R. was a 72-year-old Hun- garian, who had had a carcinoma of the right breast removed twenty years previously. He was admitted because of a three-month history of intractable pain in his right hip, thigh, knee, and to some extent where his right leg had been (his right leg had been amputated below the knee during World War I, because of injuries and subsequent infection). Neurological examination failed to reveal any abnormality and there were significant emotional factors in his background. For these reasons hypnotherapy was suggested.

He was a translator of scientific articles, had been a teacher of natural sciences, and, when he lived in Vienna, hypnosis was a new development used in the detection of crime and in the treatment of shell shock. Although he was fear- ful of being hypnotized, he quickly entered a deep trance and was made to relive his past life, which he described in German. In doing so he re-experienced pain in his right extremity and abreacted the appropriate emotional con- comitants-a phenomenon like the “crises” described by Mesmer. Following this the patient was awakened. His pain had disappeared. The next day he said he felt as though “his body and soul had been torn apart,” and that he remembered people he had not seen for dec- ades. Although he continued to complain of pain in his thigh, it was not severe and in no way did it affect his sleeping. He refused fur-

10 CANCER .January 1954 VOl. 7

ther hypnosis, and a contemplated neurosurgi- cal operation was decided not to be indicated. He left the hospital two weeks later and did not return for follow-up.

Case 8. H. J. was a 50-year-old man who had had a radical removal of a malignant testicular tumor nine months previously. Following this, extensive radiotherapy was given to his abdomen and lower back. For the past four months, he has had low-back and bilateral leg pain; for two months, spasms of the lower abdomen and legs shook the patient rhythmically and spasmodically day and night. An electromyo- gram demonstrated forty regular spasms per minute. A myelogram and roentgenograms re- vealed no evidence of a metastatic tumor.

The patient said on his first interview, “The only time I’ve been free of pain in the past four months was when my mind didn’t know it.” When only a medium trance could he obtained after three attempts at hypnosis, intravenous sodium amytal was combined with the hypnotic procedure. During this interview it was learned how he had been affected by the suffering of his father, who had died of cancer a few years previously. His father had had severe leg pains comparable to the patient’s. The patient had also tried to get some drug to put his father “out of his misery,” but, before he could accomplish this act, his father died. There was considerable expression of feeling about this by the patient. The parallelism he had made between himself and his father, as well as his self-imposed punishment, was pointed out to him. During this interview the lower abdominal and leg spasms stopped completely, and following it the patient said that he felt “at peace with the world,” and “his legs were absolutely quiet for the first time in three months.” A similar result followed a second interview of narcohypnosis and in a few days the patient was discharged from the hospital 90 per cent improved.

Not long after returning home where family, relatives, and well-meaning friends gave him consolation, his spasms and pains returned with even greater severity.

Case 9. Mrs. E. S. was a 52-year-old colored woman with a stage-IV carcinoma of the cervix. Weekly cervical biopsies were taken for a research study until the patient became so afraid of the pain of the procedure she would not permit it. Hypnosis was induced and a medium trance with partial skin anesthesia was obtained. The cervical biopsy was taken easily. The next week, the patient resisted being hypnotized, but in spite of this the biopsy was taken in a medium trance. The third week it was impossible to induce a hypnotic state and the biopsy could not be taken.

CASES SEEN ON A N OUT-PATIENT BASIS

Case 10. Mrs. J. B., age 35, was seen weekly over a period of two and a half months. Two years previously she had had a radical mastectomy on the right for carcinoma. She then de- veloped an inflammatory carcinoma of the left breast with secondary metastases of the lung. There was considerable unrest at home because of a 3-year-old daughter, religious differences, and a difficult, demanding husband. She complained mainly of a burning pain and a tight feeling over her right chest, which accompanied anxiety states precipitated by arguments at home. She frequently had terrifying dreams and her sleep was disturbed by protracted periods of coughing.

A medium trance could be induced, and by suggestion her anxiety and fear could be lessened. Her chest pain and cough, however, showed little response. When she went home, the arguments and disagreements that ensued negated these effects quickly; hypnotherapy was stopped and she died two months later.

Case II. Mr. A. M. was a 55-year-old man who had had a carcinoma of the right lung partially removed by pneumonectomy five months previously. He ascribed his illness to a blow on the chest while boxing twenty years ago. The patient was a food fadist and came to the hospital for weekly visits, stooped over and complaining of severe chest pain. A medium trance was induced on three separate interviews. When awakened, the patient would cry and claim that he was finally free of pain. He would leave the hospital walking straight and smiling, but, by the time he had taken an hour’s subway ride home, he was in pain again. He died six weeks later.

Case 12. Mrs. B. L. was a 46-year-old woman who had had a carcinoma of the left breast removed locally and treated with radiotherapy fifteen years ago. Eight years ago she had a re- currence and finally submitted to a radical mastectomy but she would not permit further radiotherapy. She noticed a lump in the right axilla four years ago, which has continued to grow slowly, and she has gradually been disturbed by pain and swelling of her right arm. This area was again treated with radiotherapy.

When seen for the first time for hypnotherapy, the patient had been having pain for five months and was taking 60 mg. of codeine every four to six hours. She was seen twice a week for seven weeks. She entered only a medium trance state, but her axillary and arm pains could be relieved while entranced. During this entire time, she became less anxious, her pain lessened, and for twenty-four hours after an interview her drug requirement was reduced.

No. 1 USE OF HYPNOSIS IN CARE OF CANCER PATIENT * Butler 11

Deeply rooted obsessional neuroses that pre- vented her from riding in a car, walking alone on the street, and visiting friends were resolved by hypnotic suggestion. Besides the interviews, the patient was relieved of two attacks of acute anxiety and pain through the use of hypnosis over the telephone.

Hypnotherapy was stopped and, within a few days, the patient regressed to her former state. Then her mother died. Immediately she became worse and again had excruciating pains. Codeine was no longer adequate and she required 10 to 20 mg. of morphine sulfate every four hours. T.hree and one-half months after hypnotherapy had been stopped, the patient was seen again. Only a medium trance could be induced; pain was relieved during the trance but recurred quickly afterward. However, again her fears and anxieties were quickly and effectively brought under control. The possibility of living six months, however, precluded the use of hypnosis for this length of time and a chordotomy was advised.

DISCUSSION

Hypnosis is an altered state of mind. Philos- ophers, theologians, and scientists cannot ade- quately explain what mind is, and therefore hypnosis, which is a state of ,mind, also remains an enigma. T o describe it as a neurosis,sl a state of hypersuggeslibility,ll* 36 a period of dissociation of the brain,47 a type of conditioned reflex,60 or a hysteria19 does not take into account the facts we know about it. Let us call hypnosis that state of mind in which phenomena described as hypnotic occur.

Hypnotic techniques as used. in this study did reduce pain, allay anxiety, and aid in organ function; but the results were proportional to the depth, and only five of these selected twelve cases, who were somnambulistic, can be said to be unequivocally benefited by this therapy. The remainder of the patients who could enter a medium trance were helped, but it is doubtful if this improvement is adequate compensa- tion for the time spent to obtain it. Certainly, an out-patient basis is not satisfactory if the patient is in as much distress on returning home as when he left it.

The great amount of time and energy, pa- tience, and ingenuity required of the hypnologist to produce these results has not been ade- quately emphasized, for herein lies the chief defect in th& procedure. Certainly, we want each person to end his life with as little suffering as possible, but from a practical point of view this same energy and time could be uti-

lized by a physician in the care of someone who had a longer life expectancy. At least, in order to gain maximum relief for the time spent, one should select patients who enter’a deep or somnambulistic trance, for in these patients organic pain and subjective symptoms can be‘ relieved, and through posthypnotic suggestions relief may be continued after the period of hypnosis. Phonograph recordings are of definite value in this respect, but specificity, flexi- bility, and variety of suggested mental pictures and musical background must be kept con- stantly in mind.

The results of this study would not indicate that further efforts should be made to expand this type of therapy. However, there are two aspects of it that are obscure but, nevertheless, very important. The first is the intuitive knowledge gained by intimate association with these patients that there is a cancer personality. It is intangible and from this small experience difficult to delineate in distinctive features, but nevertheless it is a possibility worthy of further investigation. A rough sketch of this personality reveals an individual who fails to express himself; who represses hate, anger, dissatisfac- tions, and grudges; or, on the other hand, is a very “good“ person, who is consumed with self- pity and suffers in stoic silence. The future of cancer could lie in the psychosomatic approach, and the precancerous personality might be treated with psychological means. In this study of personality, one should inquire into the psy- chodynamic basis for pain, for, of two patients with apparently equal metastatic spread of disease, one will have pain and the other will not. ‘One factor demonstrated in these cases was the influence of a sense of guilt and of a need for punishment. Disease and death were not adequate retribution for the unconscious impulse to kill, to lead an immoral life, or to compensate for the lack of kindness to others. I t was necessary to add pain to balance the moral budget.

The second important finding is not the practical therapeutic aspect of emotional control, pain elimination, and organic function by means of “words,” but rather fundamental and basic evaluation of the fact that by “controlled thoughts” alone these things are possible.

Electricity and mesmerism were discovered and condemned respectively by Benjamin Franklin. Electricity has been made the servant of man, while our understanding of hypnotism has not advanced; in fact, there are reasons to suspect that Mesmer knew more about it than


he conveyed in his writings, and there is available scientific evidence to support Mesmer’s original contentions or propositions. If we knew fundamentally how the mind could eliminate pain, then possibly this knowledge could be used, freed from the disadvantages that now surround hypnotism.

Our present-day knowledge of hypnosis does not elucidate or consider the role of the hypnologist. He might as well be a flashing light or a phonograph record, but this does not explain how hypnosis affects him deleteriously. Possibly he is imperceptibly hypnotized himself and identifies himself so closely with the patient that, without his knowledge, he “becomes the patient” and after the treatment feels the negative affect he has been trying to remove with positive suggestions. It may later be proved that this results from a mesmeric influence. However, if self-analysis may be cred- ited, there is this side of the problem of which anyone who engages in hypnosis with very sick patients must be cognizant.

The suggestion that hypnosis is a “psychological” prefrontal lobotomyw has no basis in fact. At least in the cases reported here in which hypnosis was tried before and after lobotomy, hypnotizability was roughly directly proportional to the remaining ability to concentrate and inversely proportional to the completeness of the operation. It did not make the patient more easily hypnotized, as it should if it were a surgical and permanent form of the same state of mind.

Hypnotism is not to be considered lightly, for as Sir William Osle96 said, “It is a two- edged sword, and needs careful handling.” Its use must be restricted and it is safest in the hands of the competent psychiatrist, who has had a particular interest and experience with it. Other specialists and general practitioners should use it only after adequate training, and then only when other methods available are inadequate. The use of hypnotism can be com- pared to the performance of a difficult operation. Anyone can cut the skin, many may remove an appendix, but who should remove a stomach, a pancreas, or a lung? The same is true of hypnosis-anyone can learn to induce it, some can get therapeutic results, but only those with experience and training should attempt to cut out pieces of mind.

CONCLUSIONS

1. Pain, anxiety, and organ dysfunction in the cancer patient can be aided by the intensive use of hypnotherapy. The results are proportional to the depth of trance and the efficiency of the program of therapy employed.

2. Patients who easily enter a deep trance can be helped; those who reach only a medium state can be aided, although the more “organic” the complaints, the more ephemeral the response; while patients who, after repeated trials, can only enter a light stage cannot be helped by this means.

3. The main disadvantages of this form of therapy are the few good subjects, the large amount of time required, and the necessity of an experienced and well-trained hypnologist to govern each case. The possible deleterious etfect upon the health of the hypnologist and the long period of time required for one patient between onset of symptoms and death, thus limit the number of patients a single therapist could manage. Then, too, public resistance to hypnosis persists.

4. The advantages of hypnotherapy for patients who enter a deep trance are numerous. Drug requirements are lessened, pain is relieved, organ dysfunction can be corrected as much as possible, and depression, anxiety, and fear are minimized. Life is prolonged and death is approached as is a night’s sleep.

5. Prefrontal lobotomy interferes with the induction of the hypnotic state in proportion to the decreased ability of the patient to concentrate and, therefore, appears to be different from the hypnotic state.

6. Narcohypnosis helps to counteract superficial resistance but does not appear to aid otherwise in obtaining greater true hypnotic depth. It does not eliminate all resistance.

7. Future efforts should be expended to learn what hypnosis is and how i t alters physiological function. When these fundamentals are understood, its advantages will have a wider and more satisfactory application.

8. There may be a “cancer personality.” From a very intensive study of these cases, either an irihibited individual with repressed anger, hatred, and jealousy or a “good” person consumed with self-pity may be prototypes of this personality.

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13

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